Provider Demographics
NPI:1992463350
Name:TAYLOR, KELLEN
Entity type:Individual
Prefix:
First Name:KELLEN
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11711 PARK DR
Mailing Address - Street 2:
Mailing Address - City:LENNON
Mailing Address - State:MI
Mailing Address - Zip Code:48449-9307
Mailing Address - Country:US
Mailing Address - Phone:989-472-7987
Mailing Address - Fax:
Practice Address - Street 1:11410 E LENNON RD
Practice Address - Street 2:
Practice Address - City:LENNON
Practice Address - State:MI
Practice Address - Zip Code:48449-9666
Practice Address - Country:US
Practice Address - Phone:989-494-0553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant